<div class="container margin-top-single">
  <div class="row">
    <div class="col-md-10 col-md-offset-1">
      <div class="bgputih">
        <!-- judul -->
        <h1>Form</h1>
        <!-- end judul -->
        <form action="<?php echo site_url('daftar'); ?>" method="post" class="form-horizontal" role="form">
          <div class="form-group">
            <label class="col-sm-2 control-label">Nama Lengkap</label>
            <div class="col-sm-5">
              <input type="text" name="nama_lengkap" class="form-control input-sm" placeholder="Nama Lengkap">
            </div>
          </div>
          <div class="form-group">
            <label class="col-sm-2 control-label">Nama Panggilan</label>
            <div class="col-sm-5">
              <input type="text" name="nama_panggilan" class="form-control input-sm" placeholder="Nama Panggilan">
            </div>
          </div>
          <div class="form-group">
            <label class="col-sm-2 control-label">Alamat</label>
            <div class="col-sm-7">
              <textarea name="alamat" class="form-control input-sm" placeholder="Alamat"></textarea>
            </div>
          </div>
          <div class="form-group">
            <label class="col-sm-2 control-label">Provinsi</label>
            <div class="col-sm-5">
              <select name="provinsi" class="form-control input-sm">
                <?php
                  foreach ($provinsi as $val) {
                    echo "<option value='".$val->id_provinsi."'>".$val->provinsi."</option>";
                  }
                ?>
              </select>
            </div>
          </div>
          <div class="form-group">
            <label class="col-sm-2 control-label">Email</label>
            <div class="col-sm-5">
              <input type="email" name="email" class="form-control input-sm" placeholder="Email">
            </div>
          </div>
          <div class="form-group">
            <label class="col-sm-2 control-label">No. Telp</label>
            <div class="col-sm-5">
              <input type="text" name="telp" class="form-control input-sm" placeholder="No. Telp">
            </div>
          </div>
          <div class="form-group">
            <label class="col-sm-2 control-label">Password</label>
            <div class="col-sm-5">
              <input type="password" name="password" class="form-control input-sm" placeholder="Password">
            </div>
          </div>
          <div class="form-group">
            <label class="col-sm-2 control-label">Ulangi Password</label>
            <div class="col-sm-5">
              <input type="password" name="retype_password" class="form-control input-sm" placeholder="Ulangi Password">
            </div>
          </div>
          <div class="form-group">
            <div class="col-sm-offset-2 col-sm-10">
              <button type="submit" class="btn btn-primary">Daftar</button>
              <button type="reset" class="btn btn-danger">Reset</button>
            </div>
          </div>
        </form>
        <div class="clearfix"></div>
      </div>
      
    </div>
  </div>
<div class="clearfix"></div>
</div>